Geri-Psych: Does it exist? (asked the naive new nurse)

I'm a new LPN. I've been working in LTC for the past few months. Some of my residents are elderly people with illnesses or physcal limitations who require care. Some of them are dementia patiens who can't care for themselves. Some of them are elderly people with mental illnesses which may include some kind of psychosis as well as dementia.

The third type of patient doesn't mix well with the first two. The patients with no cognitive symptoms and the pleasantly demented are usually a joy to be around. We have a few disturbed individuals on our unit, however, who scream, curse, act out, and disrupt the environment for the other patients.

I'm bothered by this for two reasons. The first is that I think sick, elderly, disabled or dying people deserve the dignity of a calm, peaceful environment. The psych patients in the mix make my unit a very unpleasant place to be. I feel awful for everyone, especially the cancer patients who have come there to spend their final days. No one should have to listen to shrieking and swearing as they are dying.

The second reason is the psych patients themselves. Their agitation looks like sufferring to me. We try to reduce their medications because the meds are seen as chemical restraints. But don't psych meds take the patient's pain away to an extent? I watch these people through my shift and they are clearly sufferring.

What happens in my area is this: A geriatric person is found disheveld bt family members. They go into the hospital on a 72 hour psych hold. In the hospital they are stabilized, cleaned up, and medicated. Then they are shipped out to a nursing home, and the meds are D/Ced. As soon as the meds are gone they become aggittated and/or violent. I can't blame them for that. I would do the same if removed from my home against my will.

I think this is a lousy model, and doesn't really address the needs of the patients. They are not being treated for mental illness. They are not encouraged to thrive to the extent that they are able. They are just being warehoused. Do other parts of the country do things differently?

I'm not sure things are done much differently in other parts of the country, but, yes, gero psych is a subspecialty within psych and there are professionals who specialize in gero psych. There are also dedicated gero psych units in some hospitals -- but, like anything else, some are good, some mediocre, and some bad.

I'm not sure I understand why the medications people were stabilized on in the hospital would be d/c'd at a SNF. Do they also routinely d/c people's cardiac meds, insulin, etc.?? Why wouldn't they be continued on the meds they came on?

Dec 27, '12

I see exactlty what the OP has decribed! But imagine this...our facility is changing more to short term rehab with younger residents...they get to be mixed in with the geri psych that we get. Geri psych is a sub speciality! I think a lot of the reasons we get the not too stabilized patients is that there are no beds for these patients in the local hospital units and they are too heathy to be in a reg med surg bed?

As far as the "stabilized with meds"...I dunno if snowing them with haldol, risperidol etc counts. Med management takes a while...at least a week or two for most drugs to become theraputic. Haldol etc is used just to "snow" them in the meantime...when there is no bed in a geri psych unit..they gotta go some where and then end up in LTC..those meds are either cut before or right after discharge from the hospital. Now...lets mention the dose reductions that LTCs do....better yet..lets not, haha. It gets me wound up when we spend so much time getting the right dose of meds then the pharm consultant comes around and wants to cut it..grrrr.

I see exactlty what the OP has decribed! But imagine this...our facility is changing more to short term rehab with younger residents...they get to be mixed in with the geri psych that we get. Geri psych is a sub speciality! I think a lot of the reasons we get the not too stabilized patients is that there are no beds for these patients in the local hospital units and they are too heathy to be in a reg med surg bed?

As far as the "stabilized with meds"...I dunno if snowing them with haldol, risperidol etc counts. Med management takes a while...at least a week or two for most drugs to become theraputic. Haldol etc is used just to "snow" them in the meantime...when there is no bed in a geri psych unit..they gotta go some where and then end up in LTC..those meds are either cut before or right after discharge from the hospital. Now...lets mention the dose reductions that LTCs do....better yet..lets not, haha. It gets me wound up when we spend so much time getting the right dose of meds then the pharm consultant comes around and wants to cut it..grrrr.

I have done psych consultation in nursing homes in MA and NH. Agitated demented pts are often treated with low dose second generation antipsychotics, mood stabilizers, labs to rule out UTI etc.
I might try a dose reduction, or document why it is not appropriate.
There may be psych APRN's in your area who could consult..

Dec 29, '12

This question cuts close to home for me.

My mother became more and more confused living at home and would be found wandering the streets in the snow at night or walking to the ER at least twice a week and the ER was over a mile away. The sheriff finally told my brother, who is her legal rep for medical and financial issues, that he had to do something because they weren't going to keep responding every time my mom escaped from the house. Our local ER was getting tired of seeing her walk in too. Adult Protective Services was involved. She was finally admitted to a local LTC but became very agitated, angry and destructive - one of the docs had to tackle her once because she was attacking staff and Haldol was given. They had to hire one-on-one CNA's for her 24/7 - these were traveling CNA's whom ake more money than the RN's up here and it was too costly for the hospital. It took the social worker 3 months to find a place for her - a lock-down facility for violent dementia patients that is 6 hours from here.

I've been to see her twice. She has no memory. Her speech is unintelligible. She fell and broke her hip but is recovered and up walking. She carries a pocketbook and a baby doll.

She was medicated with Haldol and other psychotropics but the last I checked they had weaned her off most of the drugs.

There is a very good book written by a nurse friend of mine about her father's journey through Alzheimer's. There isn't much help out there for patients like this. I'm frustrated and sad at the experience some of our family members go through due to dementia.

The book is called Who Is This Man? A Journey Through Alzheimer's by Edna Eades. I knew her dad and he was the kindest man with a good sense of humor who ended up angry and violent.

Jan 1, '13

Geriatric Psych does exist. I have worked in several areas of geriatric care and am currently working on a geri psych unit located inside a small community hospital. We provide services for many of the surrounding communities. Our program can only be effective when good follow up care is provided/utilized by family members and nursing homes. As health care providers we have to realize that some issues can not be resolved as is the case with dementia and alzheimers disease. Our team works together to help provide a more functional life for both patients and caregivers through medication and therapy. Many of our patients come to us with agitation, and agressive behaviors. Each behavior has an underlying cause that may be resolved by simply identifying and treating a physical condition such as uti, dehydration, thyroid problems or pneumonia, these issues can cause confusion and behavior changes among other things. If a person has been diagnosed with dementia he or she can be placed in medications that help slow the progression, but there is no cure. As these conditions progress behaviors change and must be addressed, insomnia, sundowning, poor appetite, weakness, and agitation. An inpatient stay is typically 2-3 weeks on a Geri Psych unit but patients can be monitored every few months with outpatient appointments with their medical doctor or psychiatrist, making med changes as needed. Some medications such as haldol can not be used long term in geriatric patients due to their tendancy to build up in the system (not excreted quickly enough) therefore causing unwanted sedation in elderly patients. These medications work well for very agitated patients to prevent injury to self or others but they must be placed on a more tolerable medication for long term use, also, some medications loose their effectiveness when used over long periods of time making med changes necessary. Good Psychiatric care for elderly patients is an ongoing process and must be treated like any other issue, assessed often with medication changes made as needed. In our area several nursing homes have specialized dementia units that offer more specialized long term care and seperate dementia/ alzheimers patients from the main population of the nursing home, providing decreased stimuli situations, strict routines and very bland decor (these sound depressing but are somewhat less agitaing to the patients). I dont know if this answers the question, "Does Geri-Psych exist?", but i hope it shines light on an often dim area of nursing.

Jan 2, '13

We have younger psych residents, rehabs & elderly. Many elderly develop mental issues related to dementia, alzheimers, etc. Unless they are paying for a private room, we have to put 2 people in the same room. If someone is really being loud & obnoxious, we try to put them with someone that has advanced dementia or alzheimers that isn't oriented & is non-verbal. We tend to put younger psych residents together, if they can get along.

Jan 2, '13

I agree with you, the LTC where I work has really lousy management for these types of patients. The hospital does discontinue all the meds they used to control them, and they get extremely wild and unmanageable soon after being admitted, putting the other residents in jeopardy. We usually work short handed, and attempting to protect the other residents is extremely exhausting and almost impossible, and who gets the blame when a resident gets attacked, the poor overworked nurse. You make many calls to the doctors, with little help. The administration is no help at all,, they claim the state won't allow us to maintain control, or have enough staff to deal with this problem. Working there is an ongoing nightmare.

I think this is a lousy model, and doesn't really address the needs of the patients. They are not being treated for mental illness. They are not encouraged to thrive to the extent that they are able. They are just being warehoused. Do other parts of the country do things differently?

Jan 3, '13

I've been working in a psych hospital for over 6 years, and I used to be an LNA on a ten-bed geri psych unit located in a community hospital while stumbling through nursing school. These demented patients DO suffer. And we who care for them are often at great risk. I'm not quite sure what evidence evidence-based-practice is looking for, but someday folks will look back at this period of time and think our policies of undermedicating angry, hostile patients made no sense at all. It doesn't preserve their quality of life, their dignity, or their loved ones from suffering more, longer. I'm convinced that if most of these folks were in their right mind, they would beg to take the med that helped them sleep instead of wail and scream in the hallway. If I ever get there, please spare me. Give me the pills.

I'm not quite sure what evidence evidence-based-practice is looking for, but someday folks will look back at this period of time and think our policies of undermedicating angry, hostile patients made no sense at all. It doesn't preserve their quality of life, their dignity, or their loved ones from suffering more, longer.

This is another example of something "we" (not those of us on this thread individually, but the larger healthcare community) brought on ourselves through abuses in the past. The current policies about restricting psych meds in long-term care settings are a result of policies and regulations introduced to correct the former practice of sedating everyone in SNFs just to keep them sedated, regardless; to make sure everyone was asleep by 7 PM and wasn't going to wake up until mid-morning, and they weren't going to have the energy or awareness to want much during the day. This was quite common a few decades ago, and the Feds and states finally got wise and decided something needed to be done. I've worked as a state regulator myself, and I can tell you that policies created by government agencies to address problems like this tend to function as sledgehammers rather than scalpels -- they tend to go too far in the other direction. So, this is what we've got for now.

There are a lot of other examples of situations like this in psych; most of the policies and regulations that provders find so challenging and difficult to live with nowadays are a reaction to abuses of the past. Stick around a while; eventually, the pendulum will swing (too far) back in the other direction. If there weren't always (it seems) "a few bad applies" in the barrel (of psych and/or SNF providers), and we all did our jobs the way we know they should be done, maybe these kind of heavyhanded policies wouldn't become necessary.

Jan 4, '13

Here in nebraska/iowa we have a geri-psych facility but it is not very big. Most still end up in nursing homes and fall through the cracks.

Apr 25, '13

Ive been working in LTC for the last 6 months. The longer I am here the more I feel that I am just working in a psych ward. It seems like 80% of our new admits since I have been working here are geri-psych. They are medicated for their psychosis but it does not seem to touch them. I had to call the other day to get an injectable ordered for a resident who refuses her oral meds. By the time I got the med ordered she had scratched, kicked, hit, and thrown objects at all of the staff, some of us were left with scratch marks and bruises. These people monopolize the nursing staff time to the point where all we have time to do is watch the psych patients and pass out meds. I feel that I have to run my entire shift around these residents. Its not fair to the rest of the people who need my time and attention. I work midnights and have a hall with 36 residents and 2 aids. Most nights the psych residents are up, and need 1:1 care. I dont know how to make my nights manegable when these people wont stay in their seats and constantly set their alarms off trying to get up or scream the house down all night, medication or not. Some of these people are 2 person assist when they get up because they are combative and large fall risks. Any advice would be appreciated, I am so frustrated.